- Over 8 years of Functional and Technical experience as a Business Analyst in working with Compliance, Clinical, Healthcare, Hospital, Insurance, Medical, Managed care, Pharmacy and Regulatory domains.
- Exceptional ability with all phases of the software development life cycle (SDLC), including Stakeholder Communication/Management, Problem Statement, Scope Creep, Gap Analysis, Feasibility Study, Requirement Analysis, Requirements gathering, Design, Development, Testing, UAT, Implementation, Deployment, Project Delivery, Warranty and Maintenance.
- Solution Proficiency with Waterfall, Iterative, Prototype and Agile methodologies.
- End to End experience with Project Inception, Project Charter, Project Design, Project Development, Project intake and Change Request Processes.
- Experience in conducting JAD Sessions, partnering with subject matter experts (SMEs) to gather and develop detailed business requirements for system implementation.
- Familiarity with Business Analysis documentation such as Business Requirements Documents (BRDs), Functional Requirements Documents (FRDs), Technical Requirements Documents (TRDs), Software Requirements Specification Documents (SRS), Software Solution Design Documents (SSDDs) and Traceability Matrix (TM) etc.
- Expertise in developing Sequence Diagrams, State Chart Diagrams, Data Flow Diagrams, Entity Relationship Diagrams and Class Diagrams.
- Expertise in using Visio to capture and document Use Cases, Flow Charts, AS IS / TO BE, Process Flow Diagrams.
- Proficient in gathering business and technical requirements during both formal and informal sessions such as JAD sessions, Interviews, Surveys, One on One sessions, Black Board Sessions, White Board Sessions, Web Meetings, video conferencing and conferences calls.
- Familiarity with various activities of insurance domain such as Enrollment, Member, Provider, Products, Benefits, Encounters, Claims, Clinical, Pharmacy, Utilization Management, HEDIS, CMS Star Ratings & NCQA Ratings etc.
- Experience with healthcare EDI HIPAA Transactions such as 276, 277, 278, 834, 835, 837, 999 (Dental, Professional, Institutional, DME (Durable Medical Equipment )) etc.
- Experience in working with End to End Claims/Encounter Life Cycle that include Claims Processing such as, Claims Adjudication, Claims Repricing, Void Claims, Duplicate Claims using Claims Systems such as Trizetto Facets and Qnxt.
- Familiar with Claims Adjudication, Premium Payment Transactions, Eligibility Reconciliation, Business Rules Configuration, Reimbursement Policies, HL7, HIPAA and Methodologies for Managed Care Organizations.
- Played a key role in the Configuration and Implementation of new markets, new products in the CSP (Community & State Platform) setting.
- Experience in various activities of the testing such as Functional, Unit, Integration, Regression, User Acceptance (UAT), Smoke, Monkey, System Load and Black Box Testing Either in manual/automation systems using Facets, Qnxt, NexGen applications and also for EDI transactions (4010/5010/X12).
- Familiar with End User Training, Documentation, Technical Writing, Crosswalk Documents, and Implementation Guides.
- Good Communication, Collaboration and Coordination skills with various groups related to the projects. Ability to handle multiple tasks while working independently or in a team setting. Experience with Offshore and on - site Coordination.
- Performing as a liaison between the Technical/Business, Functional, User, Stakeholder Teams in Translating the Business Requirements into Functional, System, Technical/Non-Technical and Operational Requirements.
- Leading the development of documentation for analysis related to the healthcare deployments to document the Functional/Business Requirements, documenting AS IS and TO BE Process Flows. Conducted JAD sessions with Technical Teams, Vendors, Business leads and Quality Assurance teams. Analyzed legacy systems, file formats, record formats, system flow charts and other information to develop a comprehensive depiction of the existing environment.
- Addressing deliverables along with the Project Manager in order to elicit, analyze, communicate, and validate requirements and business processes.
- Using the Waterfall/DevOps/Agile-Scrum Methodologies developed user stories, Business Requirements Documentation (BRD), User Requirement Document as part of the Software Development Life Cycle (SDLC).
- Designing, Developing and implementation of an Enrollment Resolution and Reconciliation Process for health insurance exchanges.
- Analyzing the discrepancies in the eligibility reconciliation process for multiple stakeholders.
- Interacting with Claims, Payments, Enrollment Teams, Real-Time Adjudication Information, hence analyzing and documenting related business processes. Producing Gap Analysis Documents for both HIPAA 5010 Enhancements.
- Analyzing the client's applications to determine the impact of the enhancements on EDI Transaction Sets and Code List implementation. Also defined the changes to bring the affected systems into compliance.
- Developing Business Crosswalks, Companion Guides for 270/271, 276/277, 835, and 837I/P, transactions per CMS - HIPAA implementation rules.
- Developing test cases based on the crosswalks and companion guidelines for 837P(Professional), 837I(Institutional) claims, for 270/271 Eligibility Inquiry and Response Documents. Working on EDI transactions, submitting, tracking claims until adjudication and Remittance Advice issued. Experience in creating and submitting Claims including Paper, Electronic/Online/Batch and Real-Time.
- Experience with Claims, Core Encounter Processing System, EPIC Reports using EPIC, NextGen and Athena Health Systems.
- Working closely with the overall project team in planning, coordinating and implementing QA methodology on various phases of the project. Analyzing results of System Testing, UAT, Regression Testing and Operational Readiness Testing performed by the Test Teams, held meetings with Clients, Management for Deliverable Approvals, Project Closure and Sign Off.
- Creating TARs (Transaction Authorization Request) that includes Paper, Electronic and Pharmacy Claim types and Transactions.
Environment: Windows 7, Facets, SQL Server, MS Visio, MS Office, Agile, Clear Case, ClearQuest, Rational Quality Manager, CHDP Systems, CMIS, CRM, Oracle, .NET, XML.
- Created Project Plans using MS Project to identify the key resource constraints, deadlines, dependencies etc. Documented & created weekly project status reports.
- Created Current Process Flows (as-is processes) & Future Process Flows (to-be processes) using MS Visio.
- Created Use Cases, Activity Diagrams, System Context Diagrams, adopting Grandfathering Processes, Pre-Existing Condition Exclusions, Dependent Coverage Age increases & other required provisions.
- Reviewed, analyzed and created BRD's. Identified Functional Requirements & Non-Functional Requirements using Rational Requisite Pro.
- Conducted interviews, brainstorming sessions, JAD sessions, presentation sessions to capture clear, concise & feasible requirements.
- Identified specific healthcare requirements & participated in development sessions to capture ERD(Entity Relationship Diagrams), Workflows & Communication diagrams.
- Familiar with Various Application Groups such as Guided Benefit Configuration, Medical Plan, Provider, Subscriber/Member and Utilization Management.
- Identified & conducted mapping process for output from 5010 to proprietary UB92 & NSF formats for legacy payer systems.
- Monitored the End-to-End implementations in working with internal and external partners such as Inbound Vendors, Plan Partners, Providers, PPGs, IPAs, Medical Groups data in compliance with HIPAA Standards.
- Involved in the End-to-End HIPAA compliance lifecycle from GAP analysis, mapping, implementation and testing for processing of Medicaid Claims. Captured key payer systems & HIPAA repository data flow issues & risks. Assisted in highlighting key aspects required for vendor solutions such as HIPAA 4010 to 5010 translators and other automated tools.
- Expertised in Claims Life Cycle, Healthcare Claims processing systems such as HealthEdge, HealthRules, HealthTrio and HealthSuite.
- Conducted Claim Adjudication (check for payer edits & rules), analyzed and identified any errors to generate 834.
- Used “UltraEdit” Professional to format ANSI X12 EDI 837I, P, D files, identified & changed duplicates, changed loops, elements & segments, wrapped & unwrapped files. Used “Ultra Compare Professional” to do 3-way comparison among ANSI X12 EDI 837I, P, D files.
- Conducted GAP analysis, Identified LOOP, SEGMENT, FIELD additions/deletions, error conditions change between As-Is process & To-Be processes for the 834 & 837 transactions.
- Logged defects using Rational ClearQuest, produced defect status reports to ensure quality standards. Conducted positive/negative testing, produced test status reports for KIOT (Knowledge Institute Of Technology) meetings using manual & automated testing methods.
Environment: Mainframes, DB2, QNXT, Rational Requisite Pro, Rational ClearQuest, Rational Test Manager, Oracle 10g, UML, MS Office, IBM Lotus Notes, Windows XP.
Confidential, Los Angeles, CA
- Gathered requirements for the healthcare applications that include Business Requirements, Use Cases, Activity Diagrams, Sequence Diagrams, Object Oriented Design (OOD), logical/ physical designs and remediation plan documents.
- Worked closely with the customers, vendors, business users, IT teams, clients and 3rd party businesses to detail in converting the business requirements into system/operational requirements.
- Involved in the full HIPAA compliance lifecycle from GAP analysis, mapping, implementation and testing for processing of Medicaid Claims. Implemented the HIPAA privacy and security regulations to enhance the capabilities of the systems to process new products.
- Familiar with medical records, patient eligibility verification, Member Demographic Changes, PCP changes, IN vs OUT OF NETWORK utilization, EOB’s, CMS Medicare Claims Processing, Manuals, Manual adds, Terminations, Retros, Capitation, CPT, ICD-10, HCPC codes, Provider Billing, Provider Office, EMR, EHR Systems, Co-Pays.
- Familiar with Member, Payer, Provider, eligibility, benefits, enrollment setting and claims, clean claims and unclean claims etc.
- Knowledge of IPA, PPG, Medical groups, HMO group plans, commercial Health Plans, PPO, Patient Assessments, PCP co-ordination, Specialist Coordination, Authorization, Eligibility Issues, Vendor Contact Managements, Eligibility file set up, Data Integrity Analysis, Field Mapping and Plan Codes.
- Developed test cases based on the crosswalks and compliance guidelines for 837 Professional and Institutional claims and for 270/271 Eligibility inquiry and response.
- Actively worked with quality control teams to develop test plans and test cases, developed tables, Views, Stored Procedures and Triggers using SQL Scripting.
Environment: OO Modeling, Facets, Web Sphere, Rational RequisitePro, Rational Rose, Rational SoDA, RUP, UML, Winrunner, Load Runner, MS-Project, MS Visio, MS Office, Windows XP.
Confidential, Los Angeles, CA
- Responsible to manage, update and report the project status, project management meetings and cost/staffing models.
- Analyzed, documented and managed the project requirements, change control throughout the software development life cycle on a weekly basis.
- Developed all the required documents (SRS, Design Document, Use Cases, Data Flow Diagram etc.) using MS Visio and MS Office.
- Created various business process quick reference guides, Architecture Flows, Process Flow Steps, departmental metrics and new project impact reports to help business partners understand the CMS guidelines.
- Facilitated the group discussions with the architects on the ways of structuring the benefits, benefit codes, rate type codes, package keys, rating modules structure, database structure and OSB (Optional Supplemental Benefit) relationships.
- Documented the workflow structure of creating the questions for the benefits, approving the benefits and rates from CMS, enrolling customers/groups to the benefits, billing cycles, claims and information printed on the ID cards.
- Experience with Member Management, Provider Management, Multiple Crosswalks, Companion Guides for Inbound/Outbound 834/837 documents using MediTrac, Care Advance, EPIC and Facets Software Systems.
- Prioritized Incidents, Defects, Root Cause Analysis, Service Desk Tickets for support & enhancement requests from business partners.
- Facilitated the implementation/coordination of the automated testing tools, design specifications, testing strategies, certify for the regression testing (For the renewal cycles), batch jobs, user acceptance testing processes, End User documentation, rollout plans/procedures, production support, maintenance support, improvements, Incidents and Remedy Requests using end-to-end IT Service Management based on ITIL framework (Information Technology Infrastructure Library).
Environment: QNXT, MS Office, SQL Server, MS Project, MS Visio, UNIX, J2ee, Java, XML, Mainframes, Windows XP.